Sam Uretsky

DEA Says Feel Your Own Pain

Top three Bill Clinton misstatements, in no particular order: 1) I
never had sex with that woman

2) The era of big government is over

3) I feel your pain.

One of the most obvious facts about pain is that it's subjective.
It can't be shared. At one time there were attempts to provide
reproducible pain for drug studies. For example, a black spot would
be painted on a subject's forehead, and a bright light focused on the
spot until the pain caused a reaction. This would be done, first
without any pain relievers, and then with various analgesics. There
was a scientific logic to the studies, but when the results were
translated to the real world, treatment of cancer pain, the results
were simply wrong. With all the medical instrumentation in the world,
pain assessment remains a subjective report by the patient, and the
observation of a nurse or physician. Accuracy is not guaranteed.

The Drug Enforcement Administra-tion, a division of the
Department of Justice, not only expects accuracy, but also compliance
with the DEA's expectations. That's why, on the DEA website, there's
still a picture of Administrator Karen Tandy holding a bag of 1,600
oral solid dosage forms (the text calls them "pills" -- the word
"pill" is commonly misused to refer to tablets or capsules, and most
modern people have never even seen a pill in the technical sense of
the word. Don't worry. The DEA is allowed to make mistakes. No one
else is.) The picture, which shows Administrator Tandy posing like
Perseus with the head of Medusa, was dated April 14, 2005, after the
successful prosecution of Dr. William Hurwitz, a Virginia pain
management specialist who, according to reports, made a sincere
effort to treat pain. Dr. Hurwitz's original conviction was
overturned, and while his retrial resulted in some convictions, it
too seems to have been marred by prosecutorial zeal. John Tierney of
the New York Times has provided excellent coverage of the
tribulations of Dr. Hurwitz, and, in part, focused on the DEA's use
of those 1,600 doses -- which turned out to be a transcription error,
and the prescriptions were never even filled.

While most of the reporting on Dr. Hurwitz's two trials shows
bias one way or the other, it seems incontrovertible that Dr. Hurwitz
prescribed large quantities of narcotic drugs for his patients, and
the DEA is anxious to have him convicted of something. When the
Commonwealth of Virginia Board of Medicine reviewed Dr. Hurwitz's
case, they found him guilty of negligence in three cases, but there
were no charges of drug trafficking. The penalty was that Dr.
Hurwitz, who had already closed his pain management practice, was
required to practice medicine only in a setting approved by the Board
and would be subject to unannounced inspections.

Unfortunately, anyone with a license to practice a profession is
as likely to be guilty of negligence at some point in their career as
anyone with a license to drive is likely to be guilty of speeding.
But, a look at the records of pain management specialists is as sure
of success as quail hunting on the Armstrong Ranch. In spite of all
the progress in medicine, some people experience severe pain which
can only be treated with narcotic analgesics. However, narcotics are
enzyme inducers -- continued use produces more liver enzymes which
metabolize the drug, so that increased, sometimes dramatically
increased, amounts are needed to provide basic pain relief. While
there are undoubtedly physicians who are dealing in improper
prescriptions, some of the most highly publicized cases seem to be
presented not on the basis of evidence of criminality, but simply
because of high prescription volume. The DEA had approved and even,
in August 2004, published pain management guidelines which might have
served as a defense for prescribers, but in November 2004 they
removed the advisory, leaving the decision on what's medically
necessary to a legal staff looking for wins.

In 1950, a University of Rochester study demonstrated that pain
was being routinely undertreated, and subsequent studies have shown
no improvement. According to the Pain Relief Network, in Florida,
Richard Paey, wheelchair bound with spinal cord injuries, was
sentenced to 25 years in prison for possession of large quantities of
narcotics, even though they were needed for his own treatment and he
had no intention of selling the drugs or offering them for sale. In
the Virgin Islands, Dr. Paul Maynard's attorney scored the minor
victory of having the doctor's sentence based on the amount of
narcotics prescribed, not total tablet weight (a tablet of Percocet
might contain 5 milligrams of oxycodone, and 300 of acetaminophen.
The original sentence included jail time for the full tablet weight
-- never mind that acetaminophen or aspirin are included in these
formulations to reduce the chances of drug abuse.)

The era of big government is back -- bigger and badder than ever.
But instead of setting rules, publishing a treatment algorithm, this
agency works through uncertainty -- and since there's no way of
knowing what the DEA will allow physicians are afraid to provide
adequate analgesia. Those physicians who try to provide adequate pain
relief get caught in a cycle, because they attract patients in
increasingly severe pain, who require more analgesia. Uncertainty can
be a more potent force than clear treatment guidelines. And for those
patients in intractable pain who can't get help, the message is
simple: take two aspirin, but don't bother to call, because nobody
feels your pain.